With dentists commenting that patient expectations appear to be higher than ever before, what are the key issues to consider in record-keeping when providing orthodontic treatment?

Great Expectations Big Bill

Like many elective treatments, one of the keys to successful orthodontic treatment is ascertaining and managing the patient’s expectations from the outset. Some patients aim for a simple cosmetic improvement, whereas others have specifications for key areas, which would be a ‘deal breaker’ if the treatment outcome does not deliver.  Some advertising material may lead a patient to believe that orthodontic treatment is much more straightforward than it actually is and patients can misunderstand the significance of their own compliance in particular treatment modes.
In reality, a practitioner is only in a position to discuss orthodontic treatment once an appropriate orthodontic assessment has been carried out. Making the appropriate record of this is crucial, as a patient complaint or claim often flows from the initial diagnosis and treatment-planning phase.
Increasingly, we are seeing patients dispute the consent process. In essence, the patient says that they were not presented with all of the appropriate information as part of the consent process, and if they had been aware, they would not have chosen the treatment that was subsequently provided.
A typical example is the patient who says: “If I had known that fixed appliances would have provided a better outcome I would never have had clear aligners”.
It is therefore essential that the consent process is appropriately documented in the records, with evidence of the relevant information provided to the patient, including treatment options, information regarding the risks and benefits, and any limitations associated with the treatment options. The record should also detail the discussions regarding the patient’s expectations, and whether or not these are likely to be met by the agreed treatment plan, a copy of the treatment plan, and compliance advice provided to the patient, including appliance wear and attendance at appropriate appointments.

Fees and other issues
In addition to this, some disputes flow from treatment fees, and it is important to ensure that the patient is aware of both the fees and any agreed payment intervals. A recent dispute arose from a patient misunderstanding the treatment fees, which he was paying at agreed intervals. The treatment was successfully completed ahead of the predicted timescale and two further agreed payments were outstanding. The patient took the view that as the treatment had concluded, any further payments should be written off. The practitioner was able to demonstrate by way of his treatment plan letter that the fees related to the treatment itself, not the duration of the treatment. In any event, in accordance with best practice, the practitioner had estimated the treatment duration but advised the patient that this was only an estimate and that treatment durations vary.
Another issue that is becoming more common in patient complaints and claims is that of retention, with patients attempting to argue that they were either unaware of the need for retention, or unaware of the significance of retention. Issues often arise if a patient is unclear as to the cost of a retainer and whether or not it is included in the initial treatment fee.
We commonly see situations where a patient has gained the impression that the initial cost of orthodontic treatment includes a lifetime of replacement retainers, when this is often not the case. It is helpful to ensure that the patient is aware of who has responsibility for checking retention, and who will provide replacement retainers when they are required.

Good records are the best defence
Many of these elements of orthodontic care can be quite obvious to practitioners; the challenge lies in ensuring that the patient is fully informed from the outset. The overall theme, therefore, is good communication between the dentist and the patient, and evidence of this in the records, so that if the practitioner is challenged at a later date the evidence is there for all to see.
The vast majority of treatments are carried out uneventfully, with the patient being satisfied with the outcome; however ,it pays to be prepared. We encourage orthodontic practitioners to consider audits of their records to see if they would provide robust evidence to any such challenge that could be made in future.

Martin Foster

Dr Martin Foster BDS MPH DipHSM
Martin is a Dento-legal Adviser at Dental Protection and spoke recently at the IDA Autumn Meeting staged with Identex.